Cervical sporotrichosis simulating squamous cell carcinoma in a patient with photodamage

61-year-old female agricultural worker, who kept domesic animals -dogs and cats without diseases -came to be ssessed. She was previously hypertensive and used losartan 0 mg/day. She reported the appearance of an erythemaous lesion on the cervical region approximately four months fter trauma caused by a tree branch. The lesion had rown over a three-month period, with pruritus and local ain, when she came for the appointment. On examinaion, a plaque with an erythematous-infiltrated border was dentified, showing a vegetating and hyperkeratotic center, overed by pustules, meliceric crusts, and black dots, on the nterior cervical region (Figs. 1A and 1B). Skin photodamage as observed around this lesion, with melanosis, leukoerma and solar elastosis. After the diagnostic hypothesis of quamous cell carcinoma (SCC), an incisional biopsy of the esion was performed. Histopathology showed pseudocarcialcohol-acid resistant bacilli was negative. The culture in modified Sabouraud agar showed a black filamentous colony with a white halo (Fig. 2), a microculture characteristic of Sporothrix spp. Oral itraconazole 200 mg/day was started and continued for two months, without clinical improvement, being replaced by potassium iodide solution 5 g/day for six months, totaling eight months of treatment. Due to the persistence of an unaesthetic scar (Fig. 3A), four cryosurgery sessions were performed, with satisfactory results (Fig. 3B). Sporotrichosis represents the most common subcutaneous mycosis in Latin America,1,2 being caused by Sporothrix spp., mainly by S. schenckii. However, in the last 20 years, S. brasiliensis infections have been increasingly reported.3 Traditionally, the infection was acquired by cutaneous inoculation of the pathogen into the body extremities after trauma, handling of soil, plants or contaminated organic material. Therefore, agriculture, mining, and floriculture were associated with a higher risk of infection, with

nomatous hyperplasia with epithelial abscesses, epithelioid granulomatous reaction and mixed inflammatory infiltrate, containing many plasma cells. Direct screening for fungi and alcohol-acid resistant bacilli was negative. The culture in modified Sabouraud agar showed a black filamentous colony with a white halo (Fig. 2), a microculture characteristic of Sporothrix spp.
Oral itraconazole 200 mg/day was started and continued for two months, without clinical improvement, being replaced by potassium iodide solution 5 g/day for six months, totaling eight months of treatment. Due to the persistence of an unaesthetic scar (Fig. 3A), four cryosurgery sessions were performed, with satisfactory results (Fig. 3B).
Sporotrichosis represents the most common subcutaneous mycosis in Latin America, 1,2 being caused by Sporothrix spp., mainly by S. schenckii. However, in the last 20 years, S. brasiliensis infections have been increasingly reported. 3 Traditionally, the infection was acquired by cutaneous inoculation of the pathogen into the body extremities after trauma, handling of soil, plants or contaminated organic material. Therefore, agriculture, mining, and floriculture were associated with a higher risk of infection, with a predominance of the lymphocutaneous clinical form in men (80%---95%). 2,3 However, a change occurred in the transmission profile in the late 1990s, being reported in the urban environment due to contact with infected cats, resulting in an increase in the number of cases in women and children, with atypical cutaneous locations. 4,5 In Brazil, this has become the most often described form of contamination in recent years. 3,5 This case report describes risk factors for both forms of contamination.
The localized cutaneous variant, as described in this case, is less frequent and manifests as a single papulonodular lesion, which may develop an infiltrated or vegetating appearance. 6 The main differential diagnoses include paracoccidioidomycosis, leishmaniasis, chromomycosis, cutaneous tuberculosis, SCC, and non-infectious ulcers. 2 There are reports in the literature of sporotrichosis simulating keratoacanthoma and Merkel cell carcinoma 7,8 but no cases mimicking SCC.
The diagnosis can be confirmed by fungal culture and microculture, 2 as in the present report. The molecular identification of the pathogen was not performed due to the unavailability of such test. The standard treatment comprises oral itraconazole (first choice), potassium iodide solution, or terbinafine. 5 Treatment duration varies according to the clinical form, fungal virulence and/or the host's immune status. Cryosurgery and electrosurgery can be combined with medication to reduce treatment duration, also being options for hyperkeratotic lesions. 5,9 In the present case report, we initially chose the standard treatment with systemic medication, complemented by cryosurgery, due to the size and location of the lesion.

Financial support
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Authors' contributions
Emily Neves Souza: design and planning of the study; drafting and editing of the manuscript; collection, analysis, and Lucia Martins Diniz: design and planning of the study; effective participation in research orientation; intellectual participation in the propaedeutic and/or therapeutic conduct of the studied case; critical review of the literature; critical review of the manuscript; approval of the final version of the manuscript.
Luana Amaral de Moura: design and planning of the study; drafting and editing of the manuscript; collection, analysis, and interpretation of data; critical review of the literature.
Valentina Lourenço Lacerda de Oliveira: design and planning of the study; drafting and editing of the manuscript; collection, analysis, and interpretation of data; critical review of the literature.
Henrique Vivacqua Leal Teixeira de Siqueira: design and planning of the study; drafting and editing of the manuscript; collection, analysis, and interpretation of data; critical review of the literature.

Dear Editor,
In Acquired Immunodeficiency Syndrome (AIDS) there is a deficiency of T-cell-mediated immunity, making the host vulnerable to opportunistic infections and malignancies. 1 It occurs when the number of CD4 cells is <200 mm 3 or in the presence of some defining condition, such as Kaposi sarcoma (KS), which is the most frequent neoplasm in these patients with diagnosis based on clinical and histopathological findings. 2,3 The present report describes a 31-year-old male patient who presented with a violaceous lesion on the oral cavity, ଝ Study conducted at the Dermatology Outpatient Clinic, Dermatology Service, Nova Esperança Faculty of Medicine, João Pessoa, PB, Brazil. which progressed in size and extension within two months, associated with intense odynophagia. He reported having sex with men. On physical examination, he had a violaceous, infiltrated tumor with areas of leukoplakia, which occupied about 70% of the hard palate (Fig. 1). In addition, he had non-painful purpuric lesions, violaceous papules, nodules and tumors on the face, scalp, cervical region, axillae and trunk, oval in shape and of different sizes (Figs. 2 and 3). Serological tests confirmed HIV and syphilis infection. The CD4 lymphocyte count was 129 mm 3 at the time of the diagnosis. Histopathology of a violaceous skin lesion showed an atypical vascular proliferation affecting the dermis and on immunohistochemistry positivity for CD31 and herpes virus 8 (HHV-8), confirming the diagnosis of KS (Fig. 4). Chest radiography and upper digestive endoscopy were performed, which showed no changes suggestive of malignancy. Antiretroviral therapy (ART) and systemic chemotherapy were started during hospitalization, with initial improvement of the lesions and overall condition. In the follow up, a new CD4 cell count was requested three months after the start of ART, disclosing a value of 320 cells/mm 3 , demonstrating improvement in relation to the first test. However,